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Recent improvements in cadaver-donor kidney retransplantation
Abstract:
1. Since 1988, 1-year graft survival rates of first cadaver transplants have improved from 78 to 80% (p less than 0.01) in both the UCLA and UNOS Renal Transplant Registries. During the same period, regraft survival has improved from 66 to 75% (p less than 0.0001) in the UNOS data and from 67 to 70% in the UCLA Registry. 2. The UCLA Registry data show a decrease in the proportion of high-risk patients [based upon previous graft survival time (PGST) less than 6 months] retransplanted each year from nearly 50% in 1986 to 35% in 1990. This decrease in a dominant risk population may contribute to rapidly improving retransplant survival. 3. Retransplanted patients with a PGST less than 6 months had a 1-year regraft survival rate of 62% versus 74% for those with a PGST longer than 6 months. 4. Sensitization, a positive crossmatch by flow cytometry, HLA-DR mismatches, and Black race were significant high-risk factors in retransplant recipients with a short PGST. For long PGST patients who rejected their previous graft more than 6 months postoperatively, these factors were far less detrimental or had no influence on the outcome. 5. The flow cytometry crossmatch improved 1-year regraft survival from 34% in 30 positive cases to 65% in 28 negative cases for the short PGST patients. More sensitive crossmatch methods may also have contributed to improving regraft survival rates. 6. The 1-year regraft survival in HLA-DR matched short PGST patients was 64% versus 52% with 2 antigens mismatched (p less than 0.01). A yearly analysis of HLA-DR mismatching showed that the number of patients with 2-DR mismatches increased whereas those with no mismatches decreased. The importance of HLA-DR mismatches should be underscored for short PGST patients. 7. Blacks with a long PGST had the same high regraft survival as Whites through the first 3 years. Blacks with a short PGST had an 8% lower 1-year regraft survival rate than Whites (p less than 0.0001). 8. Although patient selection and screening tests for preformed antibody may have contributed to rising regraft survival, the concomitant rise in first transplant survival suggests that improvements in immunosuppression strategies and patient management are also beginning to affect outcomes in the multicenter data.